PRE-OP SHORT HISTORY & PHYSICAL

Transcription

1 PRE-OP SHORT HISTORY & PHYSICAL Rev 4/16 First Name Last Name Medical History and Health Information: These uestions are for your benefit and assure that your past and present health status will be taken into consideration. Yes No Are you under the care of a physician at this time? If yes, for what condition? Are you allergic to any drugs? If yes, please list them. Have there been any changes with your medical history since the last medical examination by Dr. Novoa? Are you currently taking birth control pills? When was the date of your last menstrual period? Have you had a tubal ligation? Have you had any new surgeries the past 30 days? If yes, what type? Are you on a special diet? Do you currently smoke? When was the last date you actually smoked? Medications: Please list all current medications you are currently taking. Review of Systems General/Constitutional Skin/Breast Eyes/Ears/Nose/ Mouth/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic/Psychiatric Allergic/Immunologic/ Lymphatic/Endocrine Comment: Physical Examination WEIGHT HEIGHT BMI RESP BP PULSE TEMP General Appearance Neurological Lungs/Breasts Extremities Mental Status HEENT GI/GU Skin Exam Notes: INITIALS INITIALS I have not had any changes in my medical history over the past 30 days. I have used Birth Control without fail for the past 30 days. There is no way that I am pregnant. FOR PHYSICIAN USE ONLY Yes No Is this patient acceptable for AWAKE Surgery? Patient s Signature Doctor s Signature PREOPSHOHISTPHY-1

2 ANTIBIOTIC AND TUMESCENT SHEET Rev 4/16 First Name Last Name ACLS Protocol and Euipment Checked Medical Assistant/Nurse/Doctor Antibiotic Solution Gentamicin (80mg) Antibiotic Lot # Expiration Lot # Expiration Sterile Water 0.12% Chlorhexidine Gluconate (1pt) Tumescent Anesthetic Solution Lot # Expiration 2% (20mg) Lidocaine (0ml) 8.4% Sodium Bicarbonate (0ml) 1:1000 Epinephrine (1ml) 0.% (100mg) Ropivacaine (30ml) Notes: Doctor s Signature Medical Assistant Signature ANTTUMSHE-2

3 INTRA-OPERATIVE DOCUMENTATION SHEET FOR BREAST AUGMENTATION Rev 2/16 / / First Name Last Name of Surgery Time in PR Surgeon IV Access Started By Circulating Assistant Anesth. Start Anesth. End Surg. Start Observer Surg. End Vital Signs TIME (MIN) BP RESP PULSE OXIMETRY (%) 00 1min 30min 4min 60min 1hr 1min 1hr 30min 1hr 4min 120min 2hr 1min 2hr 30min 2hr 4min 180min 3hr 1min 3hr 30min Tumescent Preparation Patient weight in kg Max Lidocaine (mg) based on kg body weight: BAG LIDOCAINE ROPIVACAINE EPINEPHRINE SODIUM BICARBONATE Total 4 (mg) INTRAOPBREAST-3

4 NAME Last First Tumescent Infiltration AREA LEFT BREAST MIDLINE RIGHT BREAST Total 4 Spacer Documentation AIR LEFT BREAST RIGHT BREAST Implant Documentation AREA LEFT BREAST RIGHT BREAST Spacer Size Implant Type Size Saline Silicone Saline Silicone 0 ml 0 ml 100 ml 100 ml 10 ml 10 ml 200 ml 200 ml 20 ml 20 ml 300 ml 300 ml 30 ml 30 ml 400 ml 400 ml 40 ml 40 ml 00 ml 00 ml 0 ml 0 ml 600 ml 600 ml 60 ml 60 ml 700 ml 700 ml 70 ml 70 ml 800 ml 800 ml Total Amount of Air Total Amount of Air Total Amt of 0.9% Injectable Total Amt of 0.9% Injectable Doctor s Signature Medical Assistant Signature INTRAOPBREAST-4

5 POSTOPERATIVE CHECKLIST FOR COSMETIC TUMESCENT SURGERY Rev 2/16 / / First Name Last Name of Consult Post-Op Checklist After orthostatic BP and HR taken and normal, may discontinue IV heplock. Apply standard post-op sterile absorbent pads and compression garment. Give patient written After Surgery sheet, instruct patient to avoid taking lorazepam for 24hrs. Recover patient until discharge criteria met and orthostatic VS stable. May discharge 30min post-op. Vicodin /00 PO, QID, PRN, is prescribed for pain. Clindamycin 300mg PO, BID, x days Post-Operative Care & Discharge Plan Yes No Recovered in PR or RR (circle one) with RN in constant attendance. Patient tolerated procedure well. PO fluids offered ( % taken, ml taken) Moderate blood-tinged anesthetic fluid draining from incision sites. Absorbent dressings applied and explained (2 extra sets given). Compression garments applied. IV access discontinued with cannula intact & no redness or edema noted. Verbal & written post-operative instructions given. Ambulated, steady gait, to BR to void, to dressing room, dressed self (time: ) Skin warm, dry, color normal Alert, awake & oriented. Driver s Name Phone Will call at Vital Signs BP HR TIME Suspine: Sitting: Standing: Time discharged from Novoa MedSpa Doctor s Signature RN Signature Medical Assistant Signature POSTCHEABDLIPO-

6 MA AND NURSE S NOTES Rev 6/13 First Name Last Name of Birth Age DATE INTRAOPNURNOTES-6